Provider Demographics
NPI:1144045758
Name:ALLEN, BRANDY L
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46987 HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540-5146
Mailing Address - Country:US
Mailing Address - Phone:208-252-2692
Mailing Address - Fax:
Practice Address - Street 1:1706 G ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2021
Practice Address - Country:US
Practice Address - Phone:208-751-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8921930104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker